Understanding safety-netting in remote consulting

Over the past decade, there has been an increase in the number of practices offering remote consultations to patients. However, prior to the arrival of the COVID-19 pandemic, the vast majority of consultations conducted in primary care were face-to-face. The pandemic forced practices to switch to remote consulting in order to reduce the risk of viral transmission within the surgery and to enable the remote screening and assessment of patients with COVID-19 symptoms to occur. The speed at which this move from face-to-face to remote consulting took place, and the lack of a transition period during which training in remote consultation skills could occur, meant that many clinicians were thrust into remote consulting with little or no upskilling in telephone or video consulting. Clinical assessment teaching in postgraduate nurse education programmes focuses mainly on training nurses to perform face-to-face consultations and there is little or no training in the clinical assessment and clinical decision-making skills required for telephone or video consultations. The communication, clinical assessment and clinical decision-making skills differ between face-to-face and remote consultations and many clinicians who are very adept at conducting face-to-face consultations find remote consulting challenging and stressful because of the lack of training (Pygall, 2017).

There have been a number of articles published in medical journals on remote consulting in primary care but these have tended to concentrate on the logistical, technological and practical aspects of remote consulting, rather than on the differences between face-to-face and remote clinical assessments and the additional clinical decisions that need to be made when conducting remote consultations (BMJ Publishing Group, 2020). This article discusses a part of the consultation that is fundamental to the safety of patients, which is safety-netting, and describes how this should be performed during remote consultations.

Safety-netting

Safety-netting advice is given to patients to prepare them for the possibility that their symptoms and signs may worsen or not resolve as expected, and to help them identify those symptoms and signs that would indicate that there is a need for them to seek a medical re-assessment, rather than continuing to self-monitor. The fundamental principle of safety-netting is that illness is a dynamic process and that single point in time clinical assessment is only capable of eliciting those clinical findings that are present at that point in time. Since diagnosis is based on the clinical findings that are present at the time that the patient is assessed, any changes in the symptoms and signs would lead to a change in the diagnosis. This creates the potential for diagnostic uncertainty, misdiagnosis and errors in clinical decision-making. Safety-netting advice is a means of reducing the risk of serious harm coming to patients by preparing them for these potential risks and helping them to manage these risks as safely as possible.

There are 3 steps to safety-netting that apply to all consultations, whether they be conducted face-to-face, or remotely (Silverston, 2020a). The first step in safety-netting is to determine whether or not it is safe for the patient, relative, or carer to monitor the patient themselves without any further medical input. The next step is to ensure that the medical content of the advice relates to the symptoms or medical condition that the patient is presenting with, and that the advice is both clinically correct and evidence-based. The final step is to ensure that the advice is delivered in a way that can be understood and followed by the patient, their relative, or carer.

Step 1: Is it safe to safety-net?

The major difference between face-to-face consulting and remote consulting is that the patient is not in the same room as the clinician, which adds another layer of diagnostic uncertainty to the consultation and creates another clinical decision for the clinician to make. Clinical assessment teaching emphasises the importance of gathering clinical information from the patient by applying an approach that is systematic, comprehensive and holistic, including taking a set of observations and examining the patient (Silverston, 2014). Recent articles on misdiagnosis in primary care have shown that errors in diagnosis often occur when the correct clinical information is not gathered from the patient, or when that information is not gathered or interpreted correctly (Silverston, 2020b). Remote clinical assessments, especially those that are conducted by telephone, rely very heavily, or sometimes solely, on establishing the correct diagnosis by using information gathered from the history provided by the patient, relative, or carer.

While it is said that the history provides up to 90% of the information required to establish the correct diagnosis, it is also recognised that a diagnosis based solely on the history carries with it the risk of misdiagnosis. In a face-to-face clinical assessment, the history provides the clinician with a number of potential diagnoses and then further clinical information is gathered to help confirm or exclude each of those potential diagnoses. A key clinical finding may change an initial diagnosis formed from the patient's history. The inability to gather all the clinical information remotely is what creates the increased risk of errors in diagnosis and clinical decision-making in remote consulting. One of the ways of reducing these increased risks in remote consulting is to arrange for a face-to-face clinical assessment to be performed in the surgery, which, in turn, adds another layer of clinical decision-making to remote consulting, as a decision needs to be made as to which patients require a face-to-face assessment. This clinical decision has been complicated further during the COVID-19 pandemic by the requirement to balance the risk of viral transmission in the surgery with the risks of not performing a face-to-face assessment (Silverston, 2020c).

‘The 5-Cs’ safety-netting tool was developed to help clinicians gather the information required to inform their clinical decision-making with regard to whether or not it was medically appropriate and safe for the patient to monitor themselves at home, or be monitored by another lay person, rather than be monitored or re-assessed by someone with medical training (Silverston, 2020a). This tool was intended for use in face-to-face consultations but it is equally applicable in remote consultations. However, in remote consulting, a sixth ‘C’ should be added because of the requirement to assess whether or not a face-to-face clinical assessment, or re-assessment, is required, where the additional ‘C’ relates to ‘Clinical Assessment Criteria’ (Box 1). Coming to the consultation with a set of objective criteria for determining when a face-to-face assessment or re-assessment is required can help to reduce the risk of errors resulting from decisions that are idiosyncratic, off-the-cuff and not considered to be best practice. Information from national guidelines can be incorporated into these criteria, which can then be developed into practice policy for all clinicians to follow. This creates consistent, evidence-based decision-making as to when a patient requires a medical assessment, or re-assessment. It should also be borne in mind that remote consultations often take place from the patient's home, which may limit the patient's ability to disclose information. One of the criteria that would mandate a face-to-face assessment would be concerns regarding confidentiality, disclosure of personal information and patient safety within the home.

Box 1.The 6-Cs

• Have you checked the clinical assessment criteria for this symptom or medical condition?
• Is this patient/relative/carer capable of performing the lay assessment required, or is a medical assessment required?
• Is the patient mentally, physically and medico-legally competent to assess and monitor themselves, or someone else?
• Can the patient comply with your advice and instructions, practically and logistically?
• Can the patient comprehend the advice and instructions that you are providing?
• Have you confirmed that the patient has fully understood the importance of following your advice?

The mnemonic SAFER (Silverston, 2020b) can also be used to help clinicians focus on the medical content of these criteria, in terms of which serious illnesses and serious complications of minor illnesses are associated with that symptom and the red flags, risk factors and clinical findings that identify which patients are either seriously unwell now, or at increased risk of becoming seriously unwell later (Box 2). It can then be determined whether a medical assessment is required to identify the earliest symptoms and signs that indicate that the patient is not suffering from a minor illness, but is developing a serious illness or complication. This will help determine whether a lay person is capable of recognising these symptoms or signs, or whether they can only be detected by someone with medical training or diagnostic equipment. If a lay person is capable of identifying these early symptoms and signs with the appropriate safety-netting advice, then safety-netting can proceed but, if not, a face-to-face assessment is required.

Box 2.SAFER

• S = What serious causes and complications do I need to make the patient aware of?
• A = What alternative diagnoses do I need to make the patient aware of?
• F = What specific findings do I need to make the patient aware of that would mandate the need for a medical re-assessment?
• E = What early/atypical presentations of serious illnesses do I need to make the patient aware of?
• R = What red flag symptoms and signs do I need to make the patient aware of?

Step 2: Safety-netting advice

The principles of safety-netting advice are the same, whether that advice is presented in a face-to-face or a remote consultation. There are three parts to safety-netting advice, which are as follows:

• Firstly, it is important to begin by explaining the purpose of safety-netting, so that the patient or the person monitoring them truly understands the importance of following the advice that is given. A visual model can be used to convey the message that illness is a dynamic process and that the diagnosis is being made based on the symptoms and signs that are present at the time when the patient is assessed (Figure 1). A change in the symptoms and signs, or a failure in the symptoms and signs resolving with time or treatment, would mandate a medical assessment to see whether the diagnosis had changed
• Secondly, the medical content of the advice that is given must be clinically appropriate to the symptom or medical condition that the patient is presenting with and should contain information that is medically correct, evidence-based and not idiosyncratic. There are two components of safety-netting advice. The first is the generic component, which establishes the general principles of safety-netting advice (Box 3) and also provides the patient or relative with a systematic approach for detecting a general deterioration in the patient's condition (Box 4). The second part of the advice should relate to the specific symptom, or medical condition that the patient is presenting with, or that is being safety-netted for. The mnemonic SAFER can be used to help create the specific content of this advice (Silverston, 2020a).
• Finally, it is essential that safety-netting advice is delivered in a way that is patient-centred, in terms of being easy for the patient to understand and follow. This involves not only ensuring that the information is presented well in terms of having a pre-prepared safety-netting advice sheet but also that the information is delivered in such a way during the consultation that the patient will understand the importance of following the advice and be able to follow the instructions that are provided (Silverston, 2016).

Figure 1. Model of Illness

Box 3.General principlesYou should seek medical attention if:

• Your existing symptoms get worse
• New symptoms develop
• Your symptoms do not go within the time you've been told
• There is a general worsening of your condition
• You are concerned that this is not like your usual minor illness symptoms
• These symptoms and signs develop This is how you check for those symptoms & signs This is how often you should check for them during the day/during the night This is where, how and how quickly to seek medical attention, if these symptoms and signs develop, or if you are concerned that this is not a minor illness

Box 4.ABCDEF assessmentCompare these findings to your/the patient's previous experiences of a minor illness

• A = Is the patient less active than you would expect for a minor illness?
• B = Is the patient behaving differently from when they have a minor illness normally?
• C = Do the face, lips, hands or feet have an abnormal colour? (Very pale, blue or mottled?)
• D = Does the mouth, eyes, or skin appear very dry, or is the patient producing less urine than usual?
• E = Is it taking more effort than usual to breathe? (More rapid, laboured, noisy?)
• F = Does the patient have a high fever, or an abnormally low temperature?

Step 3: Delivering safety-netting advice

Studies have shown that patients may recall as little as 10% of the information imparted during a consultation, which is why it is considered best practice to deliver safety-netting advice both verbally and in writing (Houts et al, 1998; Kessels, 2003). A good example of best practice for presenting safety-netting information in written form is the Mild Head Injury Discharge Advice Sheet (Reed, 2007). Delivering safety-netting advice in a face-to-face consultation is a relatively straightforward process, as patients can be shown visual information and clinicians can demonstrate simple methods of assessing a patient and observe the patient for non-verbal clues as to whether or not the patient has understood the advice that is being given. Although it may be possible to present some information visually during a video consultation and to receive some feedback as to whether the information is being understood, this is much more difficult to perform during a telephone consultation and it still does not solve the problem of delivering written advice to support the information that is imparted verbally.

Articles that have been published on improving the quality of remote consultations have emphasised the importance of making information available to patients ahead of the consultation to improve the experience for both the patient and the clinician (Car et al, 2020). Although these articles have mostly focused on the technical and logistical aspects of remote consulting, the same approach can be adopted to delivering safety-netting advice to the patient. Information for patients on how they can prepare themselves for a remote consultation can include a section on the principles of safety-netting, including providing generic safety-netting advice. This can include an explanation of the purpose of safety-netting, with a visual model to help explain why it is required and a generic safety-netting tool, along with instructions on how to use it in different patient groups. Symptom and medical condition-specific safety-netting advice sheets can also be produced. This information can then be made available to patients either on the practice's website, or e-mailed to patients either ahead of, during, or after the consultation. Making it available to the patient ahead of, or during the consultation, will enable a discussion to be had about the contents of the advice sheet and to help the clinician to confirm whether the information provided has been understood. Another advantage of providing written information is that it helps expand on the information being given to patients without increasing the duration of the consultation itself, which is an important factor in remote consultations.

‘The communication, clinical assessment and clinical decision-making skills differ between face-to-face and remote consultations and many clinicians who are very adept at conducting face-to-face consultations find remote consulting challenging and stressful because of the lack of training.’

Conclusion

It is important to appreciate that remote consulting does increase the risk of both diagnostic and clinical decision-making errors in primary care. The inability to perform a comprehensive and holistic clinical assessment during a remote clinical assessment inevitably results in information about the patient's early physiological responses to serious illness and other clinical information not being gathered, which can lead to diagnostic uncertainty, misdiagnosis and incorrect clinical decisions being made. It is essential for safe practice that a careful risk assessment is performed before deciding whether it is both medically appropriate and clinically safe for the patient to monitor themselves, rather than come into the surgery for a face-to-face clinical assessment. Similarly, it is essential that the patient receives high-quality, best practice, safety-netting advice on how to identify when a medical assessment of their condition is required, rather than to continue with lay person monitoring, if the risk of serious harm to patients from misdiagnosis, missed diagnosis, or delayed diagnosis is to be reduced. It is also necessary to ensure that this advice is delivered in a way that patients can understand and follow, and in a form that enables them to refer back to this information hours or days after the consultation has taken place. Remote consultations are proving to be popular with many patients and also with many clinicians and there is likely to be a continued demand for this type of consulting after the threat of COVID-19 has diminished. It is important, therefore, that practices develop a system for ensuring that remote safety-netting decision-making tools are available to their clinicians and that safety-netting information is available to their patients.

KEY POINTS

• There is an increased risk of both diagnostic and clinical decision-making errors in remote consultations
• Safety-netting is an essential part of safe practice in primary care
• The first step in safety-netting in remote consulting is to determine whether the patient needs a medical assessment or re-assessment
• The medical content of safety-netting advice should contain both generic and symptom-specific components
• Safety-netting advice should be easy for the patient to understand and follow
• In remote consulting, safety-netting advice information and advice sheets can be e-mailed to the patient, or made available on the practice's website

CPD reflective practice

• What are the key differences between a clinical assessment that is performed face-to-face and one that is conducted remotely, and why does this increase the risk of diagnostic and decision-making errors?
• Why would coming to the consultation with a set of clinical assessment criteria help you with your clinical decision-making in remote consultations?
• Why is it necessary to ensure that the medical content of safety-netting advice is symptom-based and patient safety-focused and for this advice to be delivered in a way that is patient-centred?